Lecture Nursing documentation using electronic health records: Chapter 4 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 4 - Nurse note documentation, level 1. After completing Chapter 4, the students will be able to: Describe the components of a nurse note, carry out documentation of a nurse note, use chief complaints, carry out documentation of vitals (vital signs), carry out documentation of an exam (assessment).

Chapter 4

Nurse Note Documentation

Level 1

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Chapter 4 Content

LO 4.1 Nurse Note Components

LO 4.2 Documenting a Nurse Note – Level 1

LO 4.3 Chief Complaints

LO 4.4 Vitals (Vital Signs)

LO 4.5 Exam (Physical Assessment)

LO 4.1 NURSE NOTE

COMPONENTS

LO 4.1 Nurse Note Components

• Nursing Documentation

– Facilitated by Charting by Exception (CBE)

– EHRs provide for rapid access to patient

information

• Nurse Note

– Area of chart for nursing documentation

LO 4.1 Nurse Note Components

• SOAPIER

S = Subjective

O = Objective

A = Assessment

P = Plan

I = Intervention

E = Evaluation

R = Revision/resolution

LO 4.2 DOCUMENTING A NURSE

NOTE

LO 4.2 Documenting a Nurse

Note

• Components of SpringChart Nurse Note

– CC (Chief Complaint),

– Vitals, Exam (Physical Assessment)

– Dx (NANDA-I/Diagnosis)

– NOC (Nursing Outcomes Classification)

– NIC (Nursing Interventions Classification)

– Test (Tests)

– Proc (Procedures)

– Teaching

– Evaluation

– Reassess (Reassessment)

• Documentation methods

– Pop-up text

– Copy previous notes

– Type

LO 4.3 CHIEF COMPLAINTS

LO 4.3 Chief Complaints

• Chief Complaint

– Issue that prompted patient to seek care

– Subjective

– Should be documented in patient’s words as

quote

LO 4.4 VITALS (VITAL SIGNS)

LO 4.4 Vitals (Vital Signs)

• Traditional vital signs

– Temperature

– Blood pressure

– Pulse

– Respirations

• Other measurements included by

SpringCharts

– Height

– Weight

– Body mass index (BMI)

– Body fat percentage

LO 4.4 Vitals (Vital Signs)

• Vitals

– Objective measurements

– May add three additional measurements such

as:

• Pulse oximeter

• Pain scale

• Height of fundus in pregnant women

LO 4.4 Vitals (Vital Signs)

• Vitals graphs

– Blood pressure

– Height

– Weight

– BMI

• Includes children’s growth charts

LO 4.5 EXAM (PHYSICAL

ASSESSMENT)

• Physical assessment

– Charting by Exception (CBE)

• May indicate normal systems – must know facility definition of “normal”

• Abnormal findings require additional detail

• Sign and Lock

– Upon completion of documentation in Nurse

Note